DOI:10.4274/tnd.47568 Turk J Neurol 2017;23:241-243
Images in Clinical Neurology / Klinik Görünüm
Neuroradiologic Findings of Intracranial Hypotension: Two Cases İntrakraniyal Hipotansiyonun Nöroradyolojik Bulguları: İki Olgu Özlem Kayım Yıldız1, Recep Dönmez1, Şeyda Figül Gökçe1, Aslı Bolayır1, Burhanettin Çiğdem1, Hatice Balaban1, Bülent Yıldız2, Ertuğrul Bolayır1, Suat Topaktaş1 1Cumhuriyet 2Cumhuriyet
University Faculty of Medicine, Department of Neurology, Sivas, Turkey University Faculty of Medicine, Department of Radiology, Sivas, Turkey
Keywords: Intracranial hypotension, magnetic resonance imaging, myelography, treatment Anahtar Kelimeler: İntrakraniyal hipotansiyon, manyetik rezonans görüntüleme, miyelografi, tedavi
Dear Editor, A 26-year-old female was admitted to hospital with orthostatic headache, blurred and double vision, nausea, vomiting, and numbness of the hands. A neurologic examination revealed left abducens nerve palsy and left peripheral facial palsy. Cranial magnetic resonance imaging (MRI) showed diffuse dural thickening and contrast enhancement and bilateral -right predominant- subdural hematoma (Figure 1). Spinal MRI and MR myelography showed multiple dural clefts, cerebrospinal fluid (CSF) accumulation around the spinal roots, and a right paracentral perineural cyst at the level of L1-2 (Figure 2, 3). The patient did not respond to bed rest, hydration, and analgesic treatment, and was treated with blood patch. A 33-year-old female was admitted to hospital with orthostatic headache, vertigo, and double vision. She had a baby with spontaneous vaginal delivery without regional anesthesia 1 month ago. Neurologic examination showed left abducens palsy. Cerebral and spinal MRI showed diffuse dural thickening and contrast enhancement. No abnormality was shown to cause CSF leakage (Figure 4). The patient responded to bed rest, hydration, and analgesic treatment. Intracranial hypotension is an intracranial pressure disorder characterized by orthostatic headache that worsens with standing
Figure 1. Cranial magnetic resonance imaging of case 1. Diffuse dural thickening and contrast enhancement and bilateral -right predominantsubacute stage subdural hematoma in axial T1 contrast-weighted imaging
Address for Correspondence/Yaz›flma Adresi: Özlem Kayım Yıldız MD, Cumhuriyet University Faculty of Medicine, Department of Neurology, Sivas, Turkey Phone: +90 346 258 07 14 E-mail:
[email protected] ORCID ID: orcid.org/0000-0002-0382-9135 Received/Gelifl Tarihi: 01.02.2017 Accepted/Kabul Tarihi: 26.05.2017 ©Copyright 2017 by Turkish Neurological Society Turkish Journal of Neurology published by Galenos Publishing House.
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Turk J Neurol 2017;23:241-243
Kayım Yıldız et al.; Neuroradiologic Findings of Intracranial Hypotension
and improves with supine position. Cranial nerve dysfunction, visual disturbances, tinnitus, cervical pain, radiculopathy, cognitive disturbances, and changes in consciousness are also seen, though less often (1). This syndrome can result from CSF leakage from dural defects caused by central nervous system trauma, lumbar puncture or epidural anesthesia, or it can develop when there are underlying degenerative changes such as disc herniations or osteophyte formations and spinal meningeal diverticulum (1). Diffuse non-nodular cerebral meningeal contrast enhancement, congestion of venous sinuses, tightening of the posterior fossa, flattening of the corpus callosum, subdural hematoma, and hygroma are the most frequent radiologic features (1). Spinal MRI can show typical imaging findings, underlying anatomic abnormalities, and play a guiding role in the management of treatment (1). MR myelography is used routinely to show CSF leakage (2). Intracranial hypotension should be kept in mind in the presence of orthostatic headache, cranial nerve palsies, and spontaneous or multiple subdural hematomas. Figure 3. Magnetic resonance myelography of case 1. Right paracentral perineural cyst at the level of L1-2 in axial spinal T2-weighted images (arrow)
Figure 4. Cranial magnetic resonance imaging of case 2. Diffuse dural thickening and contrast enhancement in axial T1 contrast-weighted imaging
Figure 2. Magnetic resonance myelography of case 1. Multiple dural clefts and cerebrospinal fluid accumulation around the spinal roots especially at the lower cervical and upper dorsal levels
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Ethics Informed Consent: Not needed. Peer-review: Internally peer-reviewed. Authorship Contributions Surgical and Medical Practices: Ö.K.Y., R.D., Ş.F.G., Concept: A.B., B.Ç., Design: H.B., Data Collection or Processing: B.Y., E.B.,
Kayım Yıldız et al.; Neuroradiologic Findings of Intracranial Hypotension
Analysis or Interpretation: S.T., Ö.K.Y., Literature Search: Ö.K.Y., Writing: Ö.K.Y. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study received no financial support.
Turk J Neurol 2017;23:241-243
References 1. Pattichis AA, Slee M. CSF hypotension: A review of its manifestations, investigation and management. J Clin Neurosci 2016;34:39-43. 2. Akbar JJ, Luetmer PH, Schwartz KM, Hunt CH, Diehn FE, Eckel LJ. The role of MR myelography with intrathecal gadolinium in localization of spinal CSF leaks in patients with spontaneous intracranial hypotension. AJNR Am J Neuroradiol 2012;33:535-540.
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